Keyhole (laparoscopic) surgery through the abdomen for treating urinary incontinence in women

Review question

We investigated whether keyhole surgery (laparoscopic colposuspension) was better than other types of surgery to treat urinary incontinence (leakage of urine) in women. We also compared different methods of laparoscopic colposuspension to each other.

Background

Urinary incontinence is a common debilitating problem for many women. Around a third of women of child-bearing age leak urine during physical exertion or when they cough, laugh or sneeze. When urinary incontinence persists after non-surgical treatment, surgery is often recommended. Laparoscopic colposuspension is an operation carried out through a small incision in the abdomen to hold and support the tissues around the neck of the bladder.

How up-to-date is this review?

The evidence is current up to 22 May 2019.

Study characteristics

We identified 26 trials with 2271 women that either compared laparoscopic colposuspension with other types of surgery for managing urinary incontinence or compared different approaches of laparoscopic colposuspension. All the trials followed up the women for at least 18 months after surgery, with some trials lasting around five years. We looked at the robustness of each trial’s methods and the number of women involved to judge the quality of the evidence they presented.

Key results

High-quality evidence means that we are confident that laparoscopic colposuspension with sutures (keyhole surgery with stitches) is as effective as open colposuspension (traditional surgery) for curing incontinence in the short term (up to 18 months after surgery). However, we are not sure whether there are fewer risks of complications during and after surgery with laparoscopic or open colposuspension.

Procedures using a midurethral sling (a sort of hammock that supports the neck of the bladder) may be as effective as laparoscopic colposuspension in curing urinary incontinence in the short term and avoiding surgical complications. Women may be less likely to need repeat surgery with a ‘sling’ than with laparoscopic colposuspension. We are not sure about these results because the evidence was low quality.

Laparoscopic colposuspension with two sutures may be better than with one suture for curing urinary incontinence in the short term, and for reducing the risk of voiding dysfunction and the need for more surgery, but there may be little difference between laparoscopic colposuspension with two sutures or with one in terms of surgical complications. Again, we are not sure about these results because the evidence was low quality.

We are very uncertain whether laparoscopic colposuspension with mesh and staples is better than open colposuspension or laparoscopic colposuspension with sutures for curing urinary incontinence. We are also very uncertain whether women who have laparoscopic colposuspension with mesh and staples or with sutures need less repeat surgery. We are very uncertain about the results because the quality of evidence was very low.

The evidence that we found relating to the effect of laparoscopic colposuspension on quality of life was inconclusive and could not be generalised.

Quality of the evidence

In general, the quality of the evidence was low. This means that we cannot be certain about the overall effectiveness of laparoscopic colposuspension compared to other treatments for urinary incontinence due to low numbers of women participating in the trials, risk of bias, and differences between trials in the statistical results.

Authors' conclusions:

The data indicate that, in terms of subjective cure of incontinence within 18 months, there is probably little difference between laparoscopic colposuspension and open colposuspension, or between laparoscopic colposuspension and midurethral sling procedures. Much of the evidence is low quality, meaning that a considerable degree of uncertainty remains about laparoscopic colposuspension. Future trials should recruit adequate numbers, conduct long-term follow-up and measure clinically important outcomes.

A brief economic commentary identified three studies. We have not quality-assessed them and they should be interpreted in light of the findings on clinical effectiveness.

Read the full abstract...

Background:

Laparoscopic colposuspension was one of the first minimal access operations for treating stress urinary incontinence in women, with the presumed advantages of shorter hospital stays and quicker return to normal activities.

This Cochrane Review was last updated in 2010.

Objectives:

To assess the effects of laparoscopic colposuspension for urinary incontinence in women; and summarise the principal findings of relevant economic evaluations of these interventions.

Thirteen trials (1304 women) compared laparoscopic colposuspension to open colposuspension and nine trials (412 women) to midurethral sling procedures. One trial (161 women) compared laparoscopic colposuspension with one suture to laparoscopic colposuspension with two sutures; and three trials (261 women) compared laparoscopic colposuspension with sutures to laparoscopic colposuspension with mesh and staples. The majority of trials did not follow up participants beyond 18 months. Overall, there was unclear risk of selection, performance and detection bias and generally low risk of attrition and reporting bias.

There is little difference between laparoscopic colposuspension using sutures and open colposuspension for subjective cure within 18 months (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.99 to 1.08; 6 trials, 755 women; high-quality evidence). We are uncertain whether laparoscopic colposuspension using mesh and staples is better or worse than open colposuspension for subjective cure within 18 months (RR 0.75, 95% CI 0.61 to 0.93; 3 trials, 362 women; very low-quality evidence) or whether there is a greater risk of repeat continence surgery with laparoscopic colposuspension. Laparoscopic colposuspension may have a lower risk of perioperative complications (RR 0.67, 95% CI 0.47 to 0.94; 11 trials, 1369 women; low-quality evidence). There may be similar or higher rates of bladder perforations with laparoscopic colposuspension (RR 1.72, 95% CI 0.90 to 3.29; 10 trials, 1311 women; moderate-quality evidence). Rates for de novo detrusor overactivity (RR 1.29, 95% CI 0.72 to 2.30; 5 trials, 472 women) and voiding dysfunction (RR 0.81, 95% CI 0.50 to 1.31; 5 trials, 507 women) may be similar but we are uncertain due to the wide confidence interval. Five studies reported on quality of life but we could not synthesise the data.

There may be little difference between laparoscopic colposuspension using sutures and tension-free vaginal tape (TVT) for subjective cure within 18 months (RR 1.01, 95% CI 0.88 to 1.16; 4 trials, 256 women; low-quality evidence) or between laparoscopic colposuspension using mesh and staples and TVT (RR 0.71, 95% CI 0.55 to 0.91; 1 trial, 121 women; low-quality evidence). For laparoscopic colposuspension compared with midurethral slings, there may be lower rates of repeat continence surgery (RR 0.40, 95% CI 0.04 to 3.62; 1 trial, 70 women; low-quality evidence) and similar risk of perioperative complications (RR 0.99, 95% CI 0.60 to 1.64; 7 trials, 514 women; low-quality evidence) but we are uncertain due to the wide confidence intervals. There may be little difference in terms of de novo detrusor overactivity (RR 0.80, 95% CI 0.34 to 1.88; 4 trials, 326 women; low-quality evidence); and probably little difference in terms of voiding dysfunction (RR 1.06, 95% CI 0.47 to 2.41; 5 trials, 412 women; moderate-quality evidence) although we are uncertain due to the wide confidence interval. Five studies reported on quality of life but we could not synthesise the data. No studies reported on bladder perforations.

Low-quality evidence indicates that there may be higher subjective cure rates within 18 months with two sutures compared to one suture (RR 1.37, 95% CI 1.14 to 1.64; 1 trial, 158 women). Comparing one suture and two sutures, one suture may have lower rates of repeat continence surgery (RR 0.35, 95% CI 0.01 to 8.37; 1 trial, 157 women) and similar risk of perioperative complications (RR 0.88, 95% CI 0.45 to 1.70) but we are uncertain due to the wide 95% CIs. There may be higher rates of voiding dysfunction with one suture compared to two sutures (RR 2.82; 95% CI 0.30 to 26.54; 1 trial, 158 women; low-quality evidence), but we are uncertain due to the wide confidence interval. This trial did not report bladder perforations, de novo detrusor overactivity or quality of life.

We are uncertain whether laparoscopic colposuspension with sutures is better or worse for subjective cure within 18 months compared to mesh and staples (RR 1.24, 95% CI 0.96 to 1.59; 2 trials, 180 women; very low-quality evidence) or in terms of repeat continence surgery (RR 0.97, 95% CI 0.06 to 14.91; 1 trial, 69 women; very low-quality evidence). Laparoscopic colposuspension with sutures may increase the number of perioperative complications compared to mesh and staples (RR 1.94, 95% CI 1.09 to 3.48; 3 trials, 260 women; low-quality evidence) but rates of de novo detrusor overactivity may be similar (RR 0.72, 95% CI 0.17 to 3.06; 2 trials, 122 women; low-quality evidence), however, we are uncertain due to the wide confidence interval. None of the studies reported bladder perforations, voiding dysfunction or quality of life.

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